What is the use of Tegretol (carbamazepine) in the Intensive Care Unit (ICU)?

From the Guidelines

The use of TEG (thromboelastography) or ROTEM (rotational thromboelastometry) in ICU settings is not directly addressed in the provided guidelines, which focus on pain, agitation, and delirium management in adult ICU patients 1. However, considering the importance of coagulation management in critically ill patients, it is essential to discuss the role of TEG/ROTEM in ICU settings. TEG and ROTEM are point-of-care viscoelastic hemostatic assays used to rapidly assess coagulation status and guide blood product administration. These tests provide real-time information about clot formation, strength, and breakdown, offering advantages over conventional coagulation tests. In the ICU, TEG/ROTEM is particularly valuable for managing bleeding in trauma, cardiac surgery, liver transplantation, obstetric hemorrhage, and sepsis-induced coagulopathy. The test requires a small blood sample (about 300 microliters) and provides results within 10-30 minutes. When implementing TEG/ROTEM, clinicians should establish institutional protocols for test interpretation and treatment algorithms. Parameters measured include clotting time (CT/R), clot formation time (CFT/K), maximum clot firmness (MCF/MA), and clot lysis. Treatment is guided by specific parameter abnormalities: prolonged CT/R suggests factor deficiency requiring plasma or factor concentrates; prolonged CFT/K with decreased MCF/MA indicates platelet dysfunction requiring platelet transfusion; isolated decreased MCF/MA suggests fibrinogen deficiency requiring cryoprecipitate or fibrinogen concentrate; and increased lysis indicates hyperfibrinolysis requiring tranexamic acid. Using TEG/ROTEM can reduce unnecessary blood product transfusions, decrease costs, and potentially improve patient outcomes by providing targeted hemostatic therapy rather than empiric transfusion strategies. Some key points to consider when using TEG/ROTEM in ICU settings include:

• Establishing institutional protocols for test interpretation and treatment algorithms
• Monitoring parameters such as clotting time, clot formation time, maximum clot firmness, and clot lysis
• Guiding treatment based on specific parameter abnormalities
• Reducing unnecessary blood product transfusions and decreasing costs
• Potentially improving patient outcomes by providing targeted hemostatic therapy. It is essential to note that the provided guidelines do not directly address the use of TEG/ROTEM in ICU settings, and the discussion above is based on general knowledge of coagulation management in critically ill patients. In clinical practice, the use of TEG/ROTEM should be guided by institutional protocols and expert opinion, taking into account the specific needs and conditions of each patient 1.

From the Research

Use of Tegaserod in ICU

• Tegaserod, a selective serotonin type 4 receptor partial agonist, has been studied for its potential use in intensive care unit (ICU) patients with impaired gastric motility 2.
• The study found that tegaserod may accelerate the return of gastric function in ICU patients with gastroparesis, providing an additional agent for the management of gastroparesis with a more favorable safety profile.
• However, the use of tegaserod in this setting has not been extensively studied, and more research is needed to fully understand its effects.

Mechanism of Action

• Tegaserod works by stimulating the serotonin type 4 receptors in the gut, which can help to improve gastric emptying and motility 3.
• This mechanism of action makes tegaserod a potential treatment option for patients with impaired gastric motility, including those in the ICU.

Safety and Efficacy

• Tegaserod has been shown to be effective in treating irritable bowel syndrome with constipation (IBS-C) and chronic constipation, with a favorable safety profile 4, 5.
• However, tegaserod was withdrawn from the market in 2007 due to concerns over adverse cardiovascular events, but was later re-approved for use in IBS-C in women under 65 years of age without heart disease or additional cardiovascular risk factors 6.
• The re-evaluation of the cardiovascular safety profile of tegaserod found that it is safe for women under 65 years of age with IBS-C, no history of cardiovascular ischemic events, and ≤1 cardiovascular risk factor 6.

Clinical Use

• Tegaserod may be considered as a treatment option for ICU patients with impaired gastric motility, particularly those with gastroparesis 2.
• However, its use should be carefully evaluated on a case-by-case basis, taking into account the patient's individual risk factors and medical history.